Fly Well

Avoiding cockpit explosions

September 1, 2010

Dr. Jonathan Sackier Why care what Blazing Saddles, U.S. Senator Bob Dole, Dole’s father, and Albert Einstein have in common? Because it affects 2 to 4 percent of adults, is the thirteenth leading killer, favors seven times more men than women, and commonly occurs at age 55. Many pilots are 50-year-old males—so you need to care!

Back at the movies, Hedley Lamarr in Mel Brooks’ classic was played by Harvey Korman, who died in 2008 from a ruptured aneurysm. The same disease killed Einstein, Senator Dole’s father, and necessitated Dole having surgery. Aneurysm originates from Greek and means “dilation” (ballooning). The aorta, the body’s main artery, carries blood from the heart into the abdomen via a diaphragmatic opening, then in front of the spine towards the pelvis. Hence the mouthful, “abdominal aortic aneurysm” or “triple A” (AAA). There is one helpful triple A, but this is not it.

High blood pressure, smoking, and genetic issues—such as Marfan syndrome (which may have afflicted Abraham Lincoln) and Ehlers-Danlos syndrome—damage arterial walls, allowing aneurysm formation. More common in Caucasians than Asians, Hispanics, or those of African descent, AAA peaks at ages 65 to 75, but can impact younger folks. As the wall weakens, internal pressure stretches the AAA, causing further weakness; it’s literally a vicious circle. Symptoms may be absent or just nagging backache or pain in the belly, neck, or “undercarriage” (British medical term for scrotum). When an aneurysm reveals itself, it may be with a bang, either by rupture (bursting) or dissection (splitting), so explosion is more fitting as rapid, often fatal bleeding may ensue, prefaced by severe back pain, abdominal bruising and swelling, then collapse from hemorrhage. Calling it rupture is like describing a thrown piston as a little spot of engine trouble. Such aneurysms are often found incidentally at annual physicals. With few symptoms, and because rupture is so dangerous, screening has merits and is often covered by insurance. Potential AAA sufferers should consult a doctor.

Physical examination may reveal a pulsating abdominal mass and if not pregnant or harboring an alien, AAA is the likely diagnosis. Next will be an ultrasound or CT scan to measure the beast’s diameter—a normal aorta is 2 centimeters (1 inch); 3 cm and greater is “aneurismal,” and more than 5.5 cm (2¼ inches), or if it’s growing fast (more than 0.5 cm/year), you just bought special time with your favorite surgeon. Between 3 to 5.5 cm, repeat semiannual measurements are prescribed. “Conservative management” (docspeak for not doing much) is imposed on smaller aneurysms, consisting of smoking cessation and controlling hypertension.

Classical surgical repair is achieved via an abdominal incision; the ballooned aorta is clamped, opened, and a synthetic tubular graft sewn inside, like a new inner tube. Bill Cook, a pilot, brilliant engineer, and medical technology legend, built Cook Medical into a global force that develops numerous paradigm-shifting innovations. In the past couple of decades his company and others introduced a new technique, endovascular aneurysm repair (EVAR). Through a puncture hole in the groin, a cunningly folded device is deployed into the diseased artery, opened, and secured. EVAR’s advantages over open surgery include reduced pain, faster recovery, and earlier hospital discharge, experiences Senator Dole famously recounted after his EVAR.

Cook grew his business serving the medical community on the back of general aviation. I spoke to Kem Hawkins, company president, about their work with EVAR. “We focus on innovation to improve patient outcomes—as endovascular therapy grows in popularity, people can return to the things that they love to do, like flying airplanes.” Dr. Charles McIntosh, chief medical officer and cardiovascular surgeon, referenced the U.S. Preventative Services Task Force recommendation that every male who has ever smoked and is over age 65 should have a screening ultrasound. Younger men—and women—at risk also should have this painless and potentially life-saving test.

“After conventional open surgery, follow-up tests are uncommon, but with EVAR we scan patients annually to exclude further aneurysmal growth, leaks, or device migration. Data shows that EVAR has distinct advantages over open surgery for the first few years of follow-up, with fewer deaths from the treatment itself. The difference ceases further down the line and we are still following patients,” said McIntosh.

Gary Crump, director of medical certification at AOPA, says the FAA considers any AAA above 4.5 cm aeromedically unacceptable, requiring repair to allow recertification. This may delay getting airborne again, but is preferable to taking flight with angel’s wings. Aneurysms smaller than 4.5 cm merit special issuance with annual imaging studies demonstrating less than 1.0 cm in annual diameter increase. Following AAA repair, the FAA requires cardiovascular evaluation, hospital records, a postoperative scan, and treadmill stress test to exclude coronary artery disease. Annual recertification after repair may not necessitate follow up, but if deemed medically necessary, the treating doctor’s status report and scan will be required.

AAA is like a U-Boat in the belly—silent, deep, deadly, and detected by sound waves. So drop a depth charge on this nasty disease and prevent an explosion in your cockpit.

Jonathan M. Sackier has practiced medicine in the United States for 20 years. E-mail the author at jonathan.sackier@aopa.org.